AskDocQ: U=U means if a person with HIV is undetectable, they can’t pass it on

A person with HIV who is on treatment and is undetectable cannot transmit HIV to their sexual partner. There is no risk. Zero. Brisbane LGBTIQ health specialist Dr Fiona Bisshop explains why.

I need to have a rant about U=U and HIV. I’ve written about this before, and sorry for repeating myself, but every time I think the word has been spread and I can shut up about it, I see another patient who hasn’t heard it.

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So here it is: A person with HIV who is on treatment and is undetectable cannot transmit HIV to their sexual partner.

There is no risk. Zero. It’s safe, without condoms or PrEP or prayers. The science supporting this is consistent and overwhelmingly convincing.

There have been four large studies – PARTNERS 1 and 2, Opposites Attract (an Australian study) and HPTN052, and there has never been a single proven case of linked sexual transmission in any of these studies when the positive partner is undetectable.

This includes both same-sex and heterosexual couples, and holds true for both male and female partners. Even the conservative Center for Disease Control (CDC) in the USA and the World Health Organization (WHO) both now espouse this as fact.

I recently attended the world’s largest scientific conference on HIV, CROI, in Seattle, Washington, and at a symposium on U=U the evidence was once more presented. You can view the presentation here or read more here.

If you have HIV then your healthcare provider should be able to discuss this with you, and reassure you regarding the evidence that U=U.

If you are not yet on treatment, then this information can help you to decide to start.

If you do not have HIV, but have a positive partner who is undetectable, then you should be reassured by the scientific evidence that U=U, and be relieved of any anxiety around sex and transmission.

If your partner is undetectable and you have no other sexual partners then you do not need PrEP.

Unfortunately, a recent survey showed that not all health care providers are spreading the U=U message.

This may be because they are not aware, and some because they have not yet read up on the scientific facts or they may remain unconvinced that the risk is actually zero and are not on board with the message.

They need to look at the hard evidence: PARTNERS 2 had 77,000 acts of condomless anal sex between positive and negative men, Opposites Attract had 12,000 acts.

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That’s 89,000 times that guys had anal sex without condoms and there was not a single transmission.

Now I’m not a statistician, but I think I can safely say that those figures are very convincing for zero risk. Not just reduced risk, not just extremely unlikely, but no risk.

What about viral blips you might ask? A blip is when someone who is usually undetectable has a blood test that shows a detectable but very low level of virus in their blood, usually less than 200 copies per ml.

All of the studies I mentioned used cut-offs for undetectable of between 200 and 400 copies per ml, so their definition of undetectable was higher than the definition used by our laboratories in Australia, which varies from 20 to 40 copies per ml between labs.

In other words, most low level blips would still have been counted as undetectable in the studies, and there were no transmissions. So blips should not negate the U=U message.

How long does someone have to be undetectable before U=U applies? This is a good question but technically if they have achieved undetectable status and are still taking their meds every day, they should stay undetectable, so U=U should apply straight away.

How often should viral load be checked? When someone first starts their meds their viral load is checked every three months, but once they have been undetectable for six to 12 months we can become more relaxed about monitoring, and tests need only be performed every six months.

Some would say for for someone who has been undetectable and stable on treatment for years they could even go to a single annual blood test.

If they keep taking their meds every day, nothing should change.

Currently there is no cure for HIV, but being undetectable on treatment means a person with HIV can live a normal healthy life, and along with that should be a normal sex life, free from anxiety or guilt.

It’s a human right. People with HIV are entitled to a life free of stigma and fear of transmission to their intimate partners, and the U=U message helps deliver this.